Perspective:

This is a large patient-level analysis exploring trends in outcomes among men and women undergoing TAVR over a decade. Women appear to be slightly older (1 year) with less overall comorbidities (except hypertension and lower renal clearance). Outcomes of stroke and mortality are similar between men and women. In concordance with sex-based differences in bleeding seen in patients undergoing percutaneous coronary intervention (PCI) and coronary artery bypass grafting, women undergoing TAVR had a two-fold higher risk of major bleeding. Although the types of bleeding were not captured in this study (access-site vs. non–access-site), women in general have been noted to be at increased risk for both in the PCI literature. Interplay between differences in body mass composition, anatomy, creatinine clearance, appropriate anticoagulation dosing, and other unmeasured differences most likely contribute to the excess bleeding risk seen in women. Application of bleeding avoidance strategies such as optimizing access site techniques (ultrasound guidance), using radial access for secondary access, and applying cautious anticoagulation targets may help lower the excess bleeding risk seen in women undergoing TAVR. Whether the higher bleeding rates in women are responsible for less improvement in mortality over time remains to be determined.